Background: A fifth of older adults discharged from the hospital require readmission within 30 days. Readmissions impose an enormous burden on both patients and the healthcare system. Previous investigations have found that less than half of discharged patients are able to understand and execute the discharge plan and are likely to overestimate their comprehension of the plan. It is also known that that one in four post discharge appointments are either canceled or missed by patients. Medication related omissions, adverse effects or errors are often implicated in readmissions. These findings underscore the importance of involving patients and an interdisciplinary team in the discharge process both to solicit their input and to provide effective education and counseling prior to discharge. However, the discharge process is routinely undertaken by the hospitalist, at a workstation outside of the patient’s room precluding participation by the patient or the interdisciplinary team.

Purpose: Our purpose was to reduce readmissions by designing and deploying a novel interdisciplinary and patient-centered discharge process.

Description: The hospitalists at our institution work in clinical microsystems and see patients on specified units. This project was conducted on a medical unit. First, in order to understand the contributors to readmissions for our patient population, we interviewed approximately thirty patients who were readmitted within 30 days following discharge from our unit. Our interview was focused on understanding the contributors to readmission from the patient’s perspective. Based on these insights and the existing literature on readmissions, we developed a multidisciplinary discharge process called the ‘SHAPE’ tool. SHAPE is an acronym guided tool to ensure adequate Social Support, assessment and arrangements for Home Health care, reviewing Appointments (and why they are important) scheduled after discharge, reviewing Prescriptions using a teach back method, and assessing Education needs or questions prior to discharge. An interdisciplinary team consisting of the discharging physician, staff pharmacist, residents, and when available the bedside nurse, reviews each component with the patient at the bedside on the day of discharge. We trialed this process with patients who were assigned to the unit based team, being discharged home on a weekday, had an extensive medication list and were not delirious or demented. We tracked baseline and post intervention 30- day readmission rates on patients discharged from our unit to assess the impact of SHAPE.

Conclusions: The SHAPE discharge process began on June 1, 2017. Prior to this, the unit’s average monthly 30 day readmission rate from December 2016 through May 2017 was 14.39%. After the initiation of SHAPE, the average monthly readmission rate from June 2017 through November 2017 decreased to 11.85%., an absolute 2.5% reduction in 30 day readmissions. The most common intervention triggered by utilization of SHAPE was the removal of barriers to obtaining medications prior to discharge, including prior authorizations and cost issues. As SHAPE is time consuming, its efficacy may be further enhanced by tools that better identify patients who are both at risk for preventable readmissions and will benefit from the intervention.An interdisciplinary, patient-centered discharge process to address barriers faced by patients following discharge, may decrease readmissions.